Alexander, a contributing writer to the Atlantic, has written an important and unsettling book about the American health non-system.  Granted remarkably full access to Bryan Hospital in a town of 8500 people in northwest Ohio, he weaves two parallel narratives into a powerful insider look at how the hospital/insurance/pharma/medical equipment industrial complex fails to deliver its over-priced product to people in need.

I was initially hesitant to read this book after perusing the review of it in the NYT Book Review, but succumbed when I saw it on the shelf at the Cambridge Public Library. My hesitancy was the result of spending 40 years on both sides of the hospital world, first as a physician and then as an executive.  The challenges facing Bryan Hospital were the ones I had spent years struggling with—a bottom line that determined our ability to carry out our mission, doctors demanding higher salaries and acting badly (one such event proved to be the downfall of the CEO at Bryan despite decades of outstanding performance), ever higher expense and ever tighter reimbursement, difficult negotiations with insurers, suppliers, nurses’ unions, and an ever sicker population beset by the deterioration in the social determinants of health, i.e. primarily poverty and its sequelae.

Alexander is a formidable critic of the health care industry with its ever escalating costs, political clout, and dubious outcomes.  The U.S. spends twice as much on health care per capita as any other nation on earth yet our longevity and our rates of obesity, diabetes, hypertension, and cancer are among the worst in the developed world.  By taking us deeply into the lives of working people trapped in jobs that pay $9.50/hour and destroy their health, driving cars that are falling apart and that they can’t afford gas for, struggling with addiction, divorce, domestic violence, and the choices between paying for groceries, rent, or a visit to the doctor, he forces the reader to confront the inequality and unfairness of America today.

A late chapter tears into the trumpian republican approach to cutting taxes for corporations and the wealthy while cutting back public health support and other elements of the safety net.  The despair and hopelessness of those living near the edge explain their turn towards these demagogue politicians who care so little about them.

Not an easy read, but an important one.  If everyone read this book, perhaps we’d pay people a living wage, provide universal health insurance, and stop paying the CEO’s of for-profit hospitals and insurance companies outrageous salaries.  The compensation package for Hospital Corporation of America’s CEO in one year reached $109,050,062 while Keith and Stephanie Swihart  of Bryan, Ohio worked several jobs to earn a living which wasn’t enough to cover health insurance or doctor visits.  Putting the latter off, Stephanie died of advanced cervical cancer after finally seeing a doctor too late while Keith skipped his insulin doses (insulin had gone from $35/vial to over $300/vial over a period of 20 years for no reason other than pricing power of the pharma industry), lost a foot to diabetic ulcers and went blind due to diabetic retinopathy. Valerie Moreno worked three jobs to bring home $19,200/year, not enough to easily pay the $300 for her husband’s inhaler.  And on and on in a vicious cycle of low pay, poverty, illness, and early death.

Perhaps most telling was Alexander’s citing of the impact of the Reagan-era ‘government is the problem’ mantra.  In 1959 life expectancy in Oklahoma and in Connecticut was the same at 71.1 years.  At the time both states had roughly similar labor laws, wages, environment, etc.  Then lobbying and pressure from something called the  American Legislative Exchange Council funded by the Kochs and big energy, telecom, and tobacco companies led to changes in Oklahoma and other Republican-dominated states.  By 2020, the minimum wage in Oklahoma was $7.25 while Connecticut’s was $11.  By 2017, life expectancy in Connecticut was 80.7 years; in Oklahoma it was 75.8, and this difference was evident across the country in states where health, environment, and labor laws had been opposed by the ALEC.

The stakes are high in this game.  People’s lives are in the balance as huge reserves are amassed by hospitals, both for-profit and non-profit, consolidation in the insurance (e.g. CVS bought Aetna last year), pharma, and medical equipment industries gathers momentum, investments in physician groups are made by venture capital and continued reductions in public health spending continue apace.  As I had feared, just as I am about to begin to be a major user of the health care system, it is totally falling apart.  Because I am not poor and because I have been a part of this industry for decades, I will navigate it better than the poor, who it is totally failing.

A difficult read but an important one.